Risk and contraindication medical compression treatment (Part 1)

Compression therapy is the use of compression socks, stockings, boots, or bandages to apply gentle pressure to the legs. Doctors prescribed compression therapy for thousands of years. Modern science continues to discover new benefits of compression therapy. Dr. Christopher started by introducing compression classification and its importance as he discussed tension devices, and not pure pressure devices because we believe the tension is the root of most of the complications and the law of Laplace; they can be divided into two elastic compression devices, which have sustained pressure and a rise in tissue pressure, and inelastic compression, which have rapid elevations in tissue pressure.

Chris Lattimer

Risk and complications reported in the literature  

Non-severe ones are skin irritation, discomfort, and pain which are the most common events; allergies are rare, also forefoot edema and bacterial and fungal infections.  

The severe ones are fortunately scarce, meaning it is less than one in ten thousand, such as necrosis, nerve damage, and venous thromboembolism.  

However, it is essential to remember that what is reported may not reflect clinical practice because many reports are selected. There is an element of reporting and publication bias.  

Recommendation 1  

We recommend that every patient receiving compression therapy should be screened for conditions that increase the risk of complications and physicians should check every compression device for appropriate fit and application, and that the contraindications for compression treatment must be considered to limit the risk of the side effects as (severe peripheral arterial occlusive disease, epitaxial arterial bypass severe cardiac insufficiency and also a confirmed allergy to the compression material and to think carefully if the patient has insensate skin for example after a stroke or diabetic neuropathy)  


This could be considered a significant contribution to an increase in risk and may be as crucial as the ankle breaker pressure index. The dermatologists themselves are having a few issues with what to call skin fragility syndrome, chronic cutaneous fragility syndrome, cutaneous insufficiency, and age-related skin atrophy.  

Recommendation 2   

We recommend using adequate skin care to prevent skin irritation in patients with sensitive skin; this is self-evident.     

Recommendation 3  

To prevent allergic skin reactions due to compression devices, we suggest avoiding potentially allergenic substances and dyes in compression material.

The combination of a stocking with suitable creams and lotions might cause an allergy to hypersensitive people in this type of environment; if the stockings are not washed regularly, they can collect all the antigens around the house around the hospital. It is something to consider when talking about allergies to compression stockings.  

There is a Condition of compression-related dermatitis, which is hard to find in the literature; a diagnostic feature is the zone of demarcation, where the end of the lesion joins the adjacent relatively normal skin above or below.  

PPE-related dermatitis, related to COVID-19 cases, occurs on many frontline workers when they take the equipment off. It reveals the various sources, patches, and elements causal to this, often the device's moisture, friction, tension, and of course, time. There are some similarities between this and compression-related dermatitis.  

Recommendation 4  

In patients with pain or discomfort below compression garments, we recommend checking the correct indication pressure level material fitting or bandage technique and the correct donning and doffing.  The area most susceptible to discomfort is around the ankle region and sometimes the foot.  

For the correct indication, Dr. Christopher illustrated the pathophysiology of chronic venous disease, a tussle between the vein wall tension versus anti-gravitational mechanisms to cope with all of this, where compression comes in. He gave an example of a squashed minion, as when the handle is cranked, the minion gets more crushed, and its tissue pressure increase; and the same with a stocking or compression garment, and with a high tissue pressure, that aims to reduce transmural stress reduce tension.  

Another condition called tension-induced skin stress is the Appearance of circumference red lines and patches after fitting a well-applied bandage or a carefully measured stocking and concur in healthy people. It may represent the physical evidence of why compression devices can cause discomfort around the area in the legs above the ankle, particularly the border zone between tension-induced skin stress leading to compression-related dermatitis where tension lines appear and the red patches. However, they are redder, spilling over into the normal skin with small areas of redness and patches of themselves.  

Recommendation 5  

In patients with or those developing four foot or toe edema when wearing compression, we suggest considering forefoot and toe bandaging or forefoot and toe compression pieces in addition to leg compression with a foot piece.     

Recommendation 6  

In patients with bacterial or fungal infection beneath the compression device, we could recommend considering treatment with topical antiseptics or anti-microbiological medication, which seems self-evident. In patients with systemic symptoms or cellulitis, we recommend that systemic therapy be given, which is also self-evident.     

Recommendation 7  

If the compression application or material is suspected of contributing to the infection, for example, lateral pressure over the near the toes or interdigital maceration, we suggest a modification of the compression  

Dr. Christopher shared a photo of a patient with secondary lymphedema of the toes; due to prolonged compression right up to the base of the toes, she has developed an ulcer at the base of her fifth toe.  

Recommendation 8  

we suggest considering that according to the law of Laplace, the local pressure below the compression may be higher than expected at bony and tendinous prominences such as above the ankles, tibia, fibular head, or above tendons such as the Achilles tendon and to check those locations for skin lesions due to pressure.  

Recommendation 9  

To prevent tissue or necrosis nerve damage in regions with a small radius, we suggest protecting these regions from inappropriate pressure, particularly in sensitive patients, by decreasing the local pressure by inserting soft padded material and using low overall pressure. 



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